A total of 204 persons infected with the outbreak strain of Salmonella Typhimurium have been reported from 22 states linked to cantaloupes.  The number of ill persons identified in each state is as follows: Alabama (13), Arkansas (5), California (2), Florida (1), Georgia (4), Illinois (24), Indiana (22), Iowa (8), Kentucky (63), Massachusetts (2), Michigan (6), Minnesota (5), Mississippi (5), Missouri (13), New Jersey (2), North Carolina (5), Ohio (5), Pennsylvania (2), South Carolina (3), Tennessee (8), Texas (2), and Wisconsin (4).  78 ill persons have been hospitalized. Two deaths have been reported in Kentucky.

A total of 105 persons infected with the outbreak strain of Salmonella Braenderup have been reported to from 16 states since July 1, 2012 linked to mangoes.  The number of ill persons identified in each state is as follows: California (80), Delaware (1), Hawaii (3), Idaho (1), Illinois (1), Louisiana (1), Maine (1), Michigan (1), Montana (1), Nebraska (1), New Jersey (1), New York (3), Oregon (1), Texas (2), Washington (6), and Wisconsin (1).  25 ill persons have been hospitalized. No deaths have been reported.

Assuming you survive the outbreak and recover acutely, what can be the long-term consequences of a Salmonella infection.

A.        Reactive Arthritis

The term reactive arthritis refers to an inflammation of one or more joints, following an infection localized at another site distant from the affected joints.  The predominant site of the infection is the gastrointestinal tract.  Several bacteria, including Salmonella, induce septic arthritis.[1] The resulting joint pain and inflammation can resolve completely over time or permanent joint damage can occur.[2]

The reactive arthritis associated with Reiter’s may develop after a person eats food that has been tainted with bacteria. In a small number of persons, the joint inflammation is accompanied by conjunctivitis (inflammation of the eyes), and uveitis (painful urination). Id.  This triad of symptoms is called Reiter’s Syndrome.[3] Reiter’s syndrome, a form of reactive arthritis, is an uncommon but debilitating syndrome caused by gastrointestinal or genitourinary infections. The most common gastrointestinal bacteria involved are Salmonella, Campylobacter, Yersinia, and Shigella. Reiter’s syndrome is characterized by a triad of arthritis, conjunctivitis, and urethritis, although not all three symptoms occur in all affected individuals.[4]

Although the initial infection may not be recognized, reactive arthritis can still occur. Reactive arthritis typically involves inflammation of one joint (monoarthritis) or four or fewer joints (oligoarthritis), preferentially affecting those of the lower extremities; the pattern of joint involvement is usually asymmetric. Inflammation is common at enthuses—i.e., the places where ligaments and tendons attach to bone, especially the knee and the ankle.

Salmonella has been the most frequently studied bacteria associated with reactive arthritis. Overall, studies have found rates of Salmonella-associated reactive arthritis to vary between 6 and 30%.[5]  The frequency of postinfectious Reiter’s syndrome, however, has not been well described.  In a Washington State study, while 29% developed arthritis, only 3% developed the triad of symptoms associated with Reiter’s syndrome.[6]  In addition, individuals of Caucasian descent may be more likely those of Asian descent to develop reactive arthritis,[7] and children may be less susceptible than adults to reactive arthritis following infection with Salmonella.[8]

A clear association has been made between reactive arthritis and a genetic factor called the human leukocyte antigen (HLA) B27 genotype. HLA is the major histocompatibility complex in humans; these are proteins present on the surface of all body cells that contain a nucleus, and are in especially high concentrations in white blood cells (leukocytes). It is thought that HLA-B27 may affect the elimination of the infecting bacteria or an individual’s immune response.[9] HLA-B27 has been shown to be a predisposing factor in one-half to over two-thirds of individuals with reactive arthritis.[10]  While HLA-B27 does not appear to predispose to the initial infection itself, it increases the risk of developing arthritis that is more likely to be severe and prolonged. This risk may be slightly greater for Salmonella and Yersinia-associated arthritis than with Campylobacter, but more research is required to clarify this.[11]

B.        Irritable Bowel Syndrome

A recently-published study surveyed the extant scientific literature and noted that post-infectious irritable bowel syndrome (PI-IBS) is a common clinical phenomenon first-described over five decades ago.[12]  The Walkerton Health Study further notes that:

Between 5% and 30% of patients who suffer an acute episode of infectious gastroenteritis develop chronic gastrointestinal symptoms despite clearance of the inciting pathogens.[13]

In terms of its own data, the “study confirm[ed] a strong and significant relationship between acute enteric infection and subsequent IBS symptoms.”[14]  The WHS also identified risk-factors for subsequent IBS, including: younger age; female sex; and four features of the acute enteric illness—diarrhea for > 7 days, presence of blood in stools, abdominal cramps, and weight loss of at least ten pounds.[15]

Irritable bowel syndrome (IBS) is a chronic disorder characterized by alternating bouts of constipation and diarrhea, both of which are generally accompanied by abdominal cramping and pain.[16]  In one recent study, over one-third of IBS sufferers had had IBS for more than ten years, with their symptoms remaining fairly constant over time.[17]  IBS sufferers typically experienced symptoms for an average of 8.1 days per month.[18]

As would be expected from a chronic disorder with symptoms of such persistence, IBS sufferers required more time off work, spent more days in bed, and more often cut down on usual activities, when compared with non-IBS sufferers.[19]  And even when able to work, a significant majority (67%), felt less productive at work because of their symptoms.[20]  IBS symptoms also have a significantly deleterious impact on social well-being and daily social activities, such as undertaking a long drive, going to a restaurant, or taking a vacation.[21]  Finally, although a patient’s psychological state may influence the way in which he or she copes with illness and responds to treatment, there is no evidence that supports the theory that psychological disturbances in fact cause IBS or its symptoms.[22]

[1]           See J. Lindsey, “Chronic Sequellae of Foodborne Disease,” Emerging Infectious Diseases, Vol. 3, No. 4, Oct-Dec, 1997.

[2]           Id.

[3]           Id. See also, Dworkin, et al., “Reactive Arthritis and Reiter’s Syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis,” Clin. Infect. Dis., 2001 Oct. 1;33(7): 1010-4; Barth, W. and Segal, K., “Reactive Arthritis (Reiter’s Syndrome),” American Family Physician, Aug. 1999, online at www.aafp.org/afp/990800ap/499.html.

[4]           Hill Gaston JS, Lillicrap MS.  (2003).  Arthritis associated with enteric infection. Best Practices & Research Clinical Rheumatology.  17(2):219-239.

[5]           Id.

[6]           Dworkin MS, Shoemaker PC, Goldoft MJ, Kobayashi JM.  “Reactive arthritis and Reiter’s syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis.  Clin. Infect. Dis. 33(7):1010-1014.

[7]           McColl GJ, Diviney MB, Holdsworth RF, McNair PD, Carnie J, Hart W, McCluskey J, “HLA-B27 expression and reactive arthritis susceptibility in two patient cohorts infected with Salmonella Typhimurium,”  Australian and New Zealand Journal of Medicine 30(1):28-32 (2001).

[8]           Rudwaleit M, Richter S, Braun J, Sieper J, “Low incidence of reactive arthritis in children following a Salmonella outbreak,” Annals of the Rheumatic Diseases. 60(11):1055-1057 (2001).

[9]           Hill Gaston and Lillicrap, supra Note 7.

[10]          Id.; Barth WF, Segal K., “Reactive arthritis (Reiter’s syndrome).” American Family Physician.  60(2):499-503, 507 (1999).

[11]          Hill Gaston and Lillicrap, supra Note 7.

[12]          J. Marshall, et al., Incidence and Epidemiology of Irritable Bowel Syndrome After a Large Waterborne Outbreak of Bacterial Dysentery, Gastro., 2006; 131;445-50 (hereinafter “Walkerton Health Study” or “WHS”). The WHS followed one of the largest E. coli O157:H7 outbreaks in the history of North America. Contaminated drinking water caused over 2,300 people to be infected with E. coli O157:H7, resulting in 27 recognized cases of HUS, and 7 deaths. Id. at 445.  The WHS followed 2,069 eligible study participants. Id.  For Salmonella specific references, see Smith, J.L., Bayles, D.O., Post-Infectious Irritable Bowel Syndrome: A Long Term Consequence of Bacterial Gastroenteritis, Journal of Food Protection. 2007:70(7);1762-1769.

[13]          Id. at 445 (citing multiple sources).

[14]          WHS, supra note 34, at 449.

[15]          Id. at 447.

[16]          A.P.S. Hungin, et al., Irritable Bowel Syndrome in the United States: Prevalence, Symptom Patterns and Impact, Aliment Pharmacol. Ther. 2005:21 (11); 1365-75.

[17]          Id.at 1367.

[18]          Id.

[19]          Id. at 1368.

[20]          Id.

[21]          Id.

[22]          Amy Foxx-Orenstein, DO, FACG, FACP, IBS—Review and What’s New, General Medicine 2006:8(3) (Medscape 2006) (collecting and citing studies).  Indeed, PI-IBS has been found to be characterized by more diarrhea but less psychiatric illness with regard to its pathogenesis. See Nicholas J. Talley, MD, PhD, Irritable Bowel Syndrome: From Epidemiology to Treatment, from American College of Gastroenterology 68th Annual Scientific Meeting and Postgraduate Course (Medscape 2003).